Background

Breast conservation therapy (lumpectomy and adjuvant radiation) has been shown by multiple large trials to be equivalent to mastectomy in the treatment of early stage breast cancer.

There are currently multiple acceptable forms of adjuvant radiation following lumpectomy, including standard and hypofractionated whole breast irradiation (WBI) or partial breast irradiation (PBI) using brachytherapy or external beam techniques.

The recent study of CALGB-9343 found that adjuvant therapy provides less benefit for elderly women with breast cancer.

Postoperative brachytherapy for the treatment for breast cancer is reimbursed at a higher rate then more standard external beam radiotherapy (approximately $14,000 vs. $5,000 per treatment course)

Patients and policy makers may be concerned that for profit institutions may be more likely to recommend therapies with the potential of higher reimbursements.

As such, the authors performed a retrospective study of both younger and older Medicare beneficiaries with breast cancer examining whether hospital ownership status is associated with a higher use of adjuvant brachytherapy.

Materials and Methods

Using the Centers for Medicare and Medicaid Services Chronic Condition Warehouse database, the authors conducted a retrospective study of female Medicare beneficiaries aged 66-94 years old receiving breast-conserving surgery for invasive breast cancer in 2008 and 2009.

Results

Among patients who received adjuvant radiation, those who underwent surgery at for-profit hospitals were significantly more likely to receive brachytherapy than patients treated at not-for-profit hospitals (20.2% vs. 15.2%; OR for profit vs. not-for profit: 1.50; 95% CI: 1.23-1.84; p<0.001).

There was no difference in the overall percentage of patients receiving radiation therapy in for-profit compared to not-for profit hospitals (73.1% vs. 72.0%)

When breaking down the patients by age, there were similar trends towards an increase in brachytherapy use in patients who underwent surgery at for-profit centers, regardless of age group.

When specifically looking at overall radiation use the authors found the following:

In women of ages 66-79 years, there was no association between hospital profit status and overall radiation use (78.1% vs. 78.6%).

In women of age 80-94 years, having surgery at a for-profit hospital was significantly associated with higher overall radiation use (OR: 1.22; 95% CI: 1.03-1.45, p=0.03) and brachytherapy use (OR: 1.66; 95% CI: 1.18-2.34, p=0.003), but not whole breast irradiation use (OR: 1.14; 95% CI: 0.96-1.36, p=0.13). Therefore, the overall increase in radiation use is a result of an increase in brachytherapy utilization.

Author's Conclusions

Medicare beneficiaries undergoing breast-conserving surgery at for-profit hospitals were more likely to receive adjuvant brachytherapy, which is a less proven and more expensive technology.

In particular, the oldest women in the study (80-94 years) who stand to benefit least from adjuvant therapy had a higher overall radiation use at for-profit centers, with this difference largely driven by the use of brachytherapy.

The concern is that the higher reimbursement rates are driving the use of more expensive and less proven technology, particularly in a population that stand to benefit less from this therapy.

Clinical Implications

The authors presented a retrospective study examining whether hospital ownership status is associated with a higher use of adjuvant brachytherapy in patients with breast cancer treated with breast conservation therapy to due financial incentives.

This retrospective study certainly provides important information regarding how financial reimbursement may influence more expensive therapy recommendations regardless of their potential clinical benefit.

However, one large limitation of this study is that it cannot provide information about patient preference for a specific therapy.

Brachytherapy, in particular, may be preferred by more elderly patients due to its convenience of being a shorter treatment course, as well as the potential for decreased toxicity given that less breast volume is exposed to radiation.

In addition, although it is true that elderly women seem to benefit less from adjuvant radiotherapy, radiotherapy still decreases the risk of local recurrence and therefore is still beneficial in this age group.

This study highlights the importance of financial incentives in medical decision-making. This is an area that needs to be addressed in an already unsustainably expensive healthcare system, and in order to ensure patients are not being mistreated due to a practices financial prerogative.

Making decisions based on financial gain is part of human nature and not easily remedied. However, one way to address this issue is for payers to provide a financial incentive for more informed shared decision making tools so that patients are making an informed decision that is consistent with their goals of therapy and not just an expensive treatment that is being recommended for financial gain.

As we learn more about the risks and benefits of adjuvant brachytherapy as part of the treatment regimen in breast conservation therapy, if proper decision-making tools are developed and utilized, patients will then be able to make a more informed decision based on the risks and benefits of a given therapy.

Patient Summary: What Does This Mean For Me?

There are often several treatment options presented to older women with breast cancer and the cost of these can vary greatly. In turn, the reimbursement a physician or health system receives can be significantly higher for some treatments. This study evaluated if being treated at a for-profit hospital resulted in patients receiving more expensive, but not necessarily more effective treatments. They specifically looked at several methods of radiation treatment; including standard and hypofractionated whole breast irradiation (WBI) or partial breast irradiation (PBI) using brachytherapy or external beam techniques (which is given over a few days).

The study found that older women undergoing breast-conserving surgery at for-profit hospitals were more likely to receive adjuvant brachytherapy, which is a less proven and more expensive technology. In particular, the oldest women in the study (80-94 years) who stand to benefit least from adjuvant therapy had a higher overall radiation use at for-profit centers, with this difference largely driven by the use of brachytherapy. This study provides important information regarding how financial reimbursement may influence more expensive therapy recommendations regardless of their potential clinical benefit. It means that patients should explore treatment options and educate themselves through second opinions and research on reliable websites to be sure they receive appropriate therapy.